6/5/2014. Sepsis Management and Hemodynamics. 2004: International group of experts,

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1 Sepsis Management and Hemodynamics Javier Perez-Fernandez, M.D., F.C.C.P. Medical Director Critical Care Services, Baptist t Hospital of Miamii Medical Director Pulmonary Services, West Kendall Baptist Hospital Associate Clinical Professor, Herbert Wertheim College of Medicine, FIU CEO, South Florida Pulmonary and Critical Care, LLC 2004: International group of experts, representing 11 organizations, published 46 guidelines to improve outcomes 2008: Revision of these guidelines Use of GRADE system to classify strength of recommendations -> large improvement guidelines 1

2 General Principle Tissue Perfusion Pressure Flow Adequacy Hemodynamic Monitoring Correct Measurement Correct Interpretation Application How to Measure Intravascular Volume Effective intravascular volume Indirectly CVP PCWP Less indirectly Ventricular Volume = Preload Indices of Preload LVEDP LAP 2

3 Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2012 R. Phillip Dellinger, Mitchell M. Levy, Andrew Rhodes, Djillali Annane, Herwig Gerlach, Steven M. Opal, Jonathan E. Sevransky, Charles L. Sprung, Ivor S. Douglas, Roman Jaeschke, Tiffany M. Osborn, Mark E. Nunnally, Sean R. Townsend, Konrad Reinhart, Ruth M. Kleinpell, Derek C. Angus, Clifford S. Deutschman, Flavia R. Machado,Gordon D. Rubenfeld, Steven A. Webb, Richard J. Beale, Jean-Louis Vincent, Rui Moreno, and the Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. Crit Care Med 2013; 41: Intensive Care Medicine 2013;.. Antibiotic Therapy Intravenous antibiotic therapy must be started as early as possible and within the first hour of recognition of septic shock (1B) and severe sepsis without septic shock (1C). Hospital Mortality by Time to Antibiotics 3

4 Fluid therapy Crystalloids are recommended to be used in the initial fluid resuscitation of severe sepsis (Grade 1B). Albumin is recommended in the fluid resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystalloids (Grade 2C). Fluid challenge Initial fluid challenge in sepsis-induced tissue hypoperfusion (hypotension or elevated lactate) A minimum of 30mL/kg of crystalloids (a portion of this may be albumin equivalent). (Grade 1B) SSC Bundle: Sepsis 0500 To be Completed within 3 hours of the presentation : 1. Measure lactate level 2. Obtain blood cultures prior to administration of antibiotics 3. Administer broad spectrum antibiotics 4. Administer 30ml/kg crystalloid for hypotension or lactate 4mmol/L time of presentation is defined as the time of triage in the Emergency Department or, if presenting from another care venue, from the earliest chart annotation consistent with all elements severe sepsis or septic shock ascertained through chart review. 4

5 Logistic Regression Model SSC Bundle: Sepsis 0500 To be completed within 6 hours of time of presentation: 5. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure (MAP) 65mmHg) 6. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate 4 mmol/l (36mg/dl): - Measure central venous pressure (CVP)* - Measure central venous oxygen saturation (ScvO2)* 7. Re-measure lactate* * Targets for quantitative resuscitation included in the guidelines are CVP of 8 mm Hg, ScvO2 of 70% and lactate normalization. Vasopressors Norepinephrine is recommended as the first choice vasopressor (Grade 1 B). Epinephrine is suggested (added to and potentially substituted for norepinephrine) when an additional agent is needed to maintain blood pressure (Grade 2B). Vasopressin.03 units/min can be added to norepinephrine with the intent of raising MAP to target or decreasing norepinephrine dosage. (UG) 5

6 Predefined subgroup analysis by type of shock De Backer D, et al. N Engl J Med 2010, 362;9: Meta-analysis NE versus dopamine Crit Care Med Mar;40(3): Phenylephrine Pure vasopressor and in general not recommended 6

7 Sepsis Induced Tissue Hypoperfusion Requirement for vasopressors after fluid challenge Or Lactate 4 mg/dl Initial Resuscitation of Sepsis Induced Tissue Hypoperfusion Recommend Insertion central venous catheter Central venous pressure: 8 12 mm Hg Higher with altered ventricular compliance or increased intrathoracic pressure (Grade 1C) During Septic Shock Diastole Systole 10 Days Post Shock Diastole Systole 7

8 CO Measurement Indicator Dilution Doppler Arterial Pulse Wave Measurement of Ao outflow tract diameter Area = diam x π/4 SV = Area x VTI Effect on Stroke Volume P art A t Pulse Contour 8

9 Effect on Cardiac Filling Esophageal Doppler Continues measurement Less invasive than PAC Caveats Descending Ao stroke volume Probe not moving? Initial Resuscitation of Sepsis Induced Tissue Hypoperfusion Recommend Insertion central venous catheter ScvO2 saturation (SVC) 70% Grade 1C 9

10 Lactate Clearance In patients with elevated lactate levels as a marker of tissue hypoperfusion it is suggested targeting resuscitation to normalize lactate as rapidly as possible (grade 2C). Where Do The Gains Live? A B Lead Time to Diagnosis Delivery of Proper Treatment Lead time to Diagnosis & Treatment ProCESS 1 Question current protocols (mortality did not reach statistical significance) Patients received at least two liters of saline prior to randomization 18% mortality in the usual care arm (41% in Rivers paper 2 in 2001) Only addresses septic shock Two current randomized trials: The Australian Resuscitation in Sepsis Evaluation Randomised Controlled Trial (ARISE) and the Protocolised Management in Sepsis Trials (ProMISe) No serial lactate measurement 3,4 1. Angus et al. N Eng J Med 2014; 370: Rivers et al.. N Eng J Med 2001; 345: Jones et al.. JAMA 2010; 303: Jansen et al.. Am J Respir Crit Care 2010; 182:

11 Thank You!!! 11